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Abstract

The Active Low-Carber Forums (ALCF) is an on-line support group started in 2000 which
currently has more than 86,000 members. Data collected from posts to the forum and
from an on-line survey were used to determine the behavior and attitudes of people
on low carbohydrate diets. Members were asked to complete a voluntary 27-item questionnaire
over the internet. Our major findings are as follows: survey respondents, like the
membership at large, were mostly women and mostly significantly overweight, a significant
number intending to and, in many cases, succeeding at losing more than 100 lbs. The
great majority of members of ALCF identify themselves as following the Atkins diet
or some variation of it. Although individual posts on the forum and in the narrative
part of our survey are critical of professional help, we found that more than half
of respondents saw a physician before or during dieting and, of those who did, about
half received support from the physician. Another 28 % found the physician initially
neutral but supportive after positive results were produced. Using the same criteria
as the National Weight Registry (without follow-up) – 30 lbs or more lost and maintained
for more than one year – it was found that more than 1400 people had successfully
used low carb methods. In terms of food consumed, the perception of more than half
of respondents were that they ate less than before the diet and whereas high protein,
high fat sources replaced carbohydrate to some extent, the major change indicated
by survey-takers is a large increase in green vegetables and a large decrease in fruit
intake. Government or health agencies were not sources of information for dieters
in this group and a collection of narrative comments indicates a high level of satisfaction,
indeed enthusiasm for low carbohydrate dieting.

The results provide both a tabulation of the perceived behavior of a significant number
of dieters using low carbohydrate strategies as well as a collection of narratives
that provide a human perspective on what it is like to be on such a diet. An important
conclusion for the family physician is that it becomes possible to identify a diet
that is used by many people where the primary principle is replacement of starch and
sugar-containing foods with non-starchy vegetables, with little addition of fat or
protein. Used by many people who identify themselves as being on the Atkins diet,
such a strategy provides the advantages of carbohydrate-restricted diets but is less
iconoclastic than the popular perception and therefore more acceptable to traditional
nutritionists. It is reasonable for family practitioners to turn this observation
into a recommendation for patients for weight control and other health problems.

Background

Strategies for weight loss and control of diabetes and cardiovascular disease based
on carbohydrate restriction continue to be controversial. Whereas the obesity epidemic
is prima facie evidence for the limitations of traditional approaches and published
studies continue to bring out the efficacy and safety of low carbohydrate diets [1-7], official agencies and the media offer little support for the family physician and
the individual patient considering such a diet [8]. A major problem, in our view, is that the most popular of reduced carbohydrate approaches,
the Atkins diet, is an ad lib diet with recommendations only to minimize carbohydrate
intake [9]. As a result, little is known about what dieters actually do, and workers in nutrition
have consistently assumed that the lack of proscription against fat and protein means
that this constitutes a specific recommendation to increase consumption of these macronutrients.
More generally, we would suggest that the nutritional literature is lacking in what
might be called a human perspective, that is, relevant information that is lost in
the formalism of medical reporting.

This communication describes information from an on-line support group, the "Active
Low-Carber Forums (ALCF)" [10], about the behavior of dieters on low carbohydrate diets. The use of an online site,
while it falls into the category of self-reporting, has several advantages and unique
characteristics.

First, the site is primarily a support group, that is, members join the group in order
to share experiences and, because the group is anonymous and outside a clinical setting,
have little need to satisfy a mentor or personal physician and thereby less obvious
cause for bias in reporting.

In addition, the requirement for joining the group includes listing weight data and
information on diet plan used. Thus, a degree of effort is required of those people
who will be counted in the study and one can assume a certain level of seriousness.
The personal and emotional element that bears on compliance and that is necessarily
lost in statistics is salient in the forum if not always easy to quantify. It is important
to emphasize that whereas bias may appear in any human report, in many cases, perceptions
may be as important as established facts and the survey may be one of the most informative
avenues to determine this factor.

Here we describe results of examination of ALCF emphasizing an online survey.

Methods

Data for the study came from narrative information on the ALCF website posted by members,
and primarily from a survey posted on the ALCF website.

Survey

The online survey was based on the Unit Command Climate Assessment and Survey System
(UCCASS) (pronounced yoo-kas) and implemented by the director of the forum, Wa'il
al Wohaibi. UCCASS is a web-based survey script written in PHP for online surveys
and questionnaires. Details and documentation are available at the UCCASS website
[11].

The survey is available only to members of the low carbers forum at the website [10]

The completed survey is shown in the appendix [see 1] and can be seen (also requiring membership) in its original format at the Forums
website [12].

The purpose of the study is to determine the eating patterns, attitudes and general
dieting habits of members of the forum as an example of a group following a low carb
lifestyle.

Carbohydrate restriction continues to be of importance as a method for weight reduction
and treatment for diseases such as diabetes and cardiovascular disease. Scientific
studies, however, are largely restricted to an abstract, experimental setting and
there is a lack of information as to what people really do on low carbohydrate diets
and how they feel about them. This survey is designed to help provide this information.
The purpose is neither to support nor to criticize any diet but only to provide information.

Confidentiality: all information is strictly confidential and will be reported as
group data unless individual permission is obtained in advance. In the final publication,
posts on the forum may be presented. We will not use these without members' prior
permission and no identifying ID will be used.

There are 27 questions in this survey. With subsections, there are a total of 59 multiple
choices. The survey will take 5–10 minutes.

Click on the link below to start taking the survey. Please make sure to fill out the survey carefully, and
answer as many questions as possible. Once the survey is answered, it cannot be re-taken or changed.

Survey groups

Because the rationale of the survey is that the group was self-selected before the
survey, that is, less influenced by the formal experimental nature of the questionnaire,
we originally set a cut-off date (August 17, 2005, 28 days from first posting). Respondents
who registered after the cut-off were tabulated separately from those who had already
been members on the cut-off date. Results for these two groups were tabulated separately
and, as noted, below, little difference was actually found between the two groups.
In the results, dates are given for data values where they differ between groups.
Also, the survey is still active and here, again, there is little change in the percentages
of answers with time.

Filters

Correlations were obtained by use of a filter procedure in the UCASS software. With
this procedure it is possible to filter the results of the entire survey based on
answers to specific questions. For example, the responses of the sub-group of responders
who lost more than 30 lbs could be separately tabulated and compared with the group
at large or other sub-groups whose answers had been filtered. As implemented the software
has a privacy protection feature that prevents narrow filters to be used for identifying
individual responders. The default setting of 3 was used, that is, if 3 or fewer surveys
match the filter criteria, the results cannot be seen. This is to maintain anonymity
in answering the questionnaire.

Internal controls

Because filling out an online survey has no controls for attention of respondents
and because there are unknown human variables, in order to get some idea of the reliability
of answers, a few controls were built in by asking questions in different ways in
different places in the questionnaire. These are discussed in the results but, for
example, we asked in Question 2. "Have you kept at least 30 lbs off for one year or more?" and then again in Question 38. "Were you able to maintain at least 30 lbs of the weight you did lose for a year
or more?" Variations in these answers gave us a rough measure of reliability which
was typically greater than 90 %.

Background and activity of ALCF

ALCF was started in 2000 by the current director, Wa'il al Wohaibi. The forum accepts
members who are asked to enter the following information:

LC Books you have read; List some of the low-carb books you have read, this will help
users discuss books they are familiar with.

(Required)

ALCF as of May 28, 2006 has 86, 376 members and the site notes that "1,185,766 lbs lost by 57,654 members"

Results and discussion

Performance on the survey as of September 18, 2005 are shown in Appendix 1 (1) and the most current results are available on the internet at the website [12].

As noted in Methods, the original design of the survey was to run for one month.

Number of members who took the survey before the cut-off: 2, 319

Total number of respondents who registered and took the survey until January 24, 2006:
3,134

Members and respondents

The membership of ALCF is currently 83 % women, which is reflected in the makeup of
respondents to the questionnaire (as of January 24, 2006, 2579 or 82.3 % women). The
age distribution (from Q. 20) showed 61 % of respondents between 30 and 49 years of age. We did not request physical
data on the questionnaire but asked for goals in weight loss in Q. 35. The responses indicate that the starting weights must have been very high with more
than half of the people surveyed indicating that they had wanted to lose more than
50 lbs and 22 % intending to lose 100 lbs or more (Figure 1). In summary, the survey population was largely middle aged women whose goal was
to lose a large amount of body mass.

Diet plans

A non-systematic scanning of posts on the forum suggested that most members used a
personal variation of a published diet. When we asked this question specifically (Q. 35.), however, we were surprised to find that 55 % identified themselves as following
the Atkins diet and another 19 % as following "My own variation of Atkins." When results
were filtered to specifically look at the group who had lost 30 lbs or more and kept
it off for one year or more (30+1 yr) we found similar results (58 % Atkins and 22
% variation of Atkins).

This is significant in that although there are many low carbohydrate strategies available
to patients, the Atkins diet is taken as synonymous with all low carb strategies even
though from previously published reports, anecdotal evidence and the survey presented
here, there is great variation in what patients actually consume.

The meaning for the family practitioner is that the name "Atkins diet" appears to
be a permanent fixture. However, outside of the proviso on carbohydrate reduction,
it is quite flexible and individual practitioners can guide patients or design individual
plans. For example, insofar as the Forum is generalizable a family practitioner can
recommend a diet that replaces starch with non-starchy vegetables as a general strategy.
This approach is perceived as the major change by a successful group of dieters and
would hardly be criticized by most nutritionists.

The 30 lb benchmark

The survey was primarily intended to assess eating patterns and the perceptions of
dieters. We sought only a rough measure of actual weight loss. For this, an arbitrary
point of 30 lbs was set as a rough indicator of the success of dieting (Q. 1) and 62 % of respondents indicated meeting this mark. We also asked whether this
weight loss had been maintained for one year (Q. 2). This was done with reference to the National Weight Registry (NWR) cutoff that
has set a standard of having lost 30 lbs or more and kept it off for one year as a
benchmark for successful weight loss (see e.g. [13]). Although the original intent of NWR was similar to our own – to determine behavior
of dieters – it is widely quoted that their identification of 4, 000 participants
over an approximately 10 year span, most of whom had been on a low fat diet, is proof
for the efficacy of such a diet. By comparison, on the one month cut-off, we had identified
1, 088 dieters using low carbohydrate diets who had met the NWR criteria. As of January
24, 2006, the number was 1423 suggesting that whatever other information comes out
of the NWR study, evidence for superiority of low fat approaches is not a reasonable
conclusion. Most recently, the NWR has reported an increase in the daily percentage
of calories from fat and the total amount of saturated fat from 1995 to 2003 while
carbohydrate decreased from 56.0% to 49.3% in this period [14]. In addition, the limited population covered by the NWR is indicated by the fact
that 87 % of respondents to the questionnaire had never heard of the registry and
18 respondents had met their criteria, tried to register but never heard from them.

Reliability of 30 lb weight loss for one year

The NWR found that for those patients who had medical records, the reliability of
recollection was high and results generally did not require medical validation. Because
the ALCF is voluntary and members are motivated to join to share successful experiences
rather than being rewarded for success by experimenters, we think the reported values
have substantial validity. The data can, of course, be taken, simply as perceptions
of people who thought they had lost 30 lb and kept it off for one year. In any case,
as a means of built in control (see Methods) we checked responses within the questionnaire.
We filtered the results for those who answered Yes to Question 2. "Have you kept at least 30 lbs off for one year or more?" This subset was examined
for their answer to control questions. Question 1:"Have you lost 30 lbs (or more) on a low-carb plan?" This should have given 100 %
yes but was found to be only 95.78 %. Similarly, on Question 38: "Were you able to maintain at least 30 lbs of the weight you did lose for a year
or more?" 96.81 % of respondents replied yes. In other words, about 50 people in the
survey were confused about the question, were not paying attention or were otherwise
unreliable.

Lipid profile

There have been several reports on the effects of low carbohydrate diets on lipid
profiles either alone in comparison to low fat diets (Reviews: [4,15]). The general picture that emerges is that carbohydrate restriction leads to a marked
reduction in triglycerides (TAG) – this is one of the most reliable features of any
dietary intervention – and improvement in HDL. Changes in total cholesterol and LDL
tend to be variable on low carbohydrate diets but are generally considered to go down
if there is weight loss. Of current interest is the report by Krauss, et al. [16,17] that if macronutrient composition and caloric restriction are changed sequentially,
most of the beneficial effects in a low carbohydrate diet occurs during the (eucaloric)
change in macronutrients whereas the beneficial effects in a low fat diet require
weight loss. These results confirm the original report by Sharman, et al. that benefit
of a low carb diet does not require weight loss [18] and highlight the limitations of low fat diets where improvement in lipid markers
is more dependent on successful weight loss.

The survey asked if participants had had blood lipids measured before and after going
on a low carb diet (Q. 21). Forty per cent of the total group and 51 % of the 30 lb+1 yr group had done so.
As expected, from these generalizations, most of responders to the survey who had
lipids measured (Q. 22.-25.) reported a decrease in TAG (68 %) and an increase in HDL (49 %) (Table 1). The group that had kept 30 lb off for a year did noticeably better than the group
as a whole on these markers (76 % and 55 %, respectively). The table shows that 60
% of the total group and 65 % of the 30 lb+1 yr group claimed lower total cholesterol
and lower LDL which was greater than the number who had improved values for HDL. Based
on previous studies in the literature, one would have to consider the value for triglycerides
as low. It would be expected that almost everybody in the 30 lb+1 yr group would have
had decreased triglycerides. We think that these data can only be taken as semi-quantitative
and it is unlikely that respondents actually went back and checked medical records.

Physicians responses and interactions

Approximately half of the responders to the survey said that they had consulted a
physician before or during their diet (Q. 32.). One of the encouraging results from the survey was that, when queried as to how
they would describe support they received (Q. 32.), 990 (56%) of the entire group and 507 (55 %) of the 30+1 yr group who had consulted
a physician reported that the physician or health professional was supportive. An
additional 28 % and 32 % of the total and 30+1 yr groups reported that the physician
"did not have an opinion but was encouraging after seeing results." Only 6 % of responders
indicated that "they were discouraging even after I showed good results," which may
be a surprising result depending on one's relative expectations of evidence-based
medicine vs. prejudice against the Atkins diet [19-21]. The results bear on a recent paper indicating that physicians were more likely to
use a carbohydrate-restricted diet (CRD) themselves and recommend a LF diet for their
patients [22].

This result should be seen in the context of what might be described as a quandary
for most family practitioners – surveys generally show a strong feeling among physicians
of the importance of nutritional counseling but a limited ability to provide such
counseling [23-25] due to a lack of training, limitations of time or adequate reimbursement as well
as low confidence in their own ability to advise or patients' ability to comply. In
addition, there is a palpable negative response of the media and a documented bias
in the nutritional community to low carbohydrate diets [19-21]. A recent search on "Atkins" at the website of American Academy of Family Physicians
[26], for example, produced only one hit pointing to their page of "Fad diets" which includes
just about any popular diets – in other words, not just low carbohydrate diets but
any diet that is selected by individual patients is a fad. This is consistent with
the recent release of the No-Fad Diet by the American Heart Association [27] which, while it does not mention any diet by name in the book, lists low carbohydrate
diets and the grapefruit diet – the generic fad diet; does anybody know what the grapefruit
diet is? – on the dust jacket. Although again, the ALCF is a pre-selected group and
we do not know how representative of the American population they are, it is our opinion
that 80,000 people is a large number for official agencies to dismiss in such a cavalier
fashion. Again, individual practitioners appear to be open-minded and able to consider
individual success important.

Sources of information

Questions 49.-56

asked about where people obtained information. The results are shown in Table 2. and are as expected for a group following a strategy that is generally considered
outside of the mainstream of recommended medical and nutritional practice, that is,
they did not put much stock in official sources. Half of the respondents said they
felt that they relied on original scientific publications. On the question of access
to the scientific literature (Q. 57), they had this opinion:

More than adequate (could not read everything that was available): 322 (18.22%

Posts on the forum reinforce the notion that not only are official recommendations
not a source of information, they are in fact viewed with suspicion.

The following post is not uncommon:

The "health experts" are telling kids and parents the wrong foods to eat. Until we
start beating the "health experts" the kids won't get any better. If health care costs
are soaring and type 2 diabetes and its complications, as are most of these expenses
– why are we not putting a "sin" tax on high glycemic foods to cut consumption and
help pay for these cost? Beat the "health experts" – not the kids!

From the same member:

I'm not saying that it is all ignorance or all apathy – but there is a lot of ignorance
out there – because of what the "health experts" are telling the kids and parents
what is healthy. At the expense of repeating myself for the umpteenth time here is
what the "health experts" are saying is healthy: .{Wake County Public School System,
#873}

Until I researched it three years ago – I thought the most important thing was low
fat. So I was eating the hell out of low fat products and my health continued to get
worse. ...First link is a school menu and has the comment: "This is why kids are fat.
Note in the left hand column the healthy foods are animal crackers, pretzels, cake,
cookies, ice cream, pudding, milkshake, juicy juice (sugar water). Look at all the
healthy options for breakfast! Can it get any worse?"

What do people eat on a low carbohydrate diet?

Carbohydrate restriction is not well defined. Anything less than 50 % of the diet
is considered by some to be a low carbohydrate diet. From this perspective, the American
public at large was on a low carbohydrate diet before the obesity epidemic when compared
to the diet during the epidemic and certainly compared to the 55–70 % recommended
by health agencies. The problem is compounded by the fact that CRD are frequently
hypocaloric by design or due to spontaneous reduction in eating, suggesting that percentages
may be misleading. Of greater importance is probably the question of what replaces
carbohydrate. Several questions in the survey bear on this. First, a fairly general
question (Q. 4.) asked for "factors that were important in your low carb diet." Responses are shown
in Table 3:

Table 3. Responses to question 4. of the survey: which of these factors were important in your
weight loss plan? (check all that apply)

The importance of drinking water was somewhat surprising. Although a consistent recommendation
of low carbohydrate and traditional diets alike, to our knowledge, it is not based
on any real scientific evidence. It is possible that the water replaced sweetened
soft drinks which would, of course, have had a significant impact on weight loss,
but we did not ask this question directly.

The importance of vegetables was consistent with narrative posts on the forum, anecdotal
information and was further reinforced by our more detailed study of food consumption
(Q. 6.-18.) which asked about foods that were substituted for those carbohydrates that were
removed from the diet. Of total respondents, 53 % (1566) said that they had increased
their consumption of Lettuce/Salad Greens greatly (at least double usual consumption)
(Q. 16.) and 32 % (953) said that they had increased consumption slightly. Results for the
30+1 yr group were similar but more pronounced for the greatly increased category
compared to slightly increased (58 % and 28 %, respectively). Results for consumption
of green vegetables showed that increased slightly or greatly for the entire group
was 79 and 83 % for the 30+1 yr group.

These results are in distinction to responses to what might be called the three B's
mentioned by critics of low carbohydrate diets: beef, butter and bacon. Although most
people in the survey increased these at least slightly, Figure 2 shows that in the category of increased greatly, only 22 % increased one of these
foods, 10 % increased two of these foods, and only 5 % had large increases in all.
Significantly, these percentages are about the same for the 30+1 yr group.

The actual behavior with respect to vegetable consumption (Q. 26.) was as anticipated from assessment of posts on the forum: 40 % (1260) of respondents
checked the choice "I don't count carbs in non-starchy vegetables and simply eat all
I want." We are grateful to a referee for pointing out that since many low carbohydrate
diets specify grams of carbohydrates, these dieters are either not truly counting
carbohydrates or are exceeding their targets.

Food consumption. Calories and portion size

Strategies for weight loss based on carbohydrate restriction tend to downplay the
importance of conscious monitoring of caloric intake or portion size. It is generally
observed in practice that there is a spontaneous reduction in caloric intake usually
attributed to the satiating effect of protein. In our view an additional factor may
be relief from the highly reinforcing effect of carbohydrate. In any case, in combination
with the psychological benefit of freedom from constant monitoring of calories, non-cognitive
regulation of total food intake is one of the major advantages to low carbohydrate
approaches and is now appreciated by nutritional experts [28]. Similarly, portion size is generally not specified in low carb diets and macronutrient
composition appears to be sufficient to regulate total intake. Our own undocumented
guess is that a patient following a low carbohydrate diet who regularly eats a large
steak, large potato and large portion of vegetables, rather than reducing the size
of each as in official recommendations will simply remove the potato (and is unlikely
to add another steak). In that sense, a low carbohydrate diet may more closely resemble
behaviorally the habitual American diet than a low fat diet.

In addition to spontaneous caloric reduction, numerous reports in the literature point
to an advantage of increased energy inefficiency with carbohydrate restriction leading
to more weight lost per calorie consumed (Reviews: [29-32]). Popularly known as metabolic advantage, the effect is more controversial and is
not universally accepted even in the face of experimental evidence. The proposed mechanisms
for a shift in metabolic efficiency are the increased costs of processing protein
for gluconeogenesis, increased substrate cycling or the accumulated kinetic effects
of increasing lipolysis over TAG synthesis. The effect is not always seen, however,
and little is known about what particular behaviors are required to bring it about.

This question was addressed in the survey by asking respondents about their perception
of how total amount of food consumed had changed since being on a low carbohydrate
diet (Q. 31.). Half of respondents (49 %, 1524) felt that they consumed fewer calories than before
the diet, a value that was the same for the 30+1 yr group (49 %, 691). Of the remainder,
30 % said that the total calories are about the same, and 21%, that they felt as though
they consumed more calories than before the diet. This result was the same for the
group that had lost 30 lbs or more for a year. Thus, to the extent that this is an
accurate assessment of their true intake, the results from the people who ate the
same amount would support the notion of energy inefficiency since a eucaloric diet
with substantial weight loss is effectively hypocaloric. Question 30 asked about portion size and 44 % felt that they ate about the same portion size although
12 % thought that they had eaten somewhat larger portions than before the diet. The
accuracy of these perceptions is unknown. It is generally observed that dieters under-report
their consumption, although a number of researchers have claimed that dieters on low
carbohydrate diets over-report intake but this has not been experimentally demonstrated
[1,2]. Narrative reports (Q. 59) indicate that the respondents to the survey have consistently been monitoring food
throughout their lives and the results are likely to be qualitatively accurate. In
any case, half of the respondents at least had the perception that they had either
increased their food intake or maintained the amount of food in the face of substantial
weight loss which is presumably a motivating factor for compliance. This perception
is not generally considered a feature of low fat diets.

We filtered answers on Question 31, isolating the 21 % of respondents who felt that they "consume more calories than
before the diet." The food consumed by this subgroup was different than the group
at large or the 30+1 yr group. As shown in Figure 3, a higher percentage thought that they had significantly increased (more than double)
their intake of meat, fish and butter, the largest effect being seen in the larger
percentage who had increases of beef (32 % compared to 21 %). This subgroup was also
somewhat less likely to have increased their consumption of vegetables although if
they actually eat more food may have consumed the same absolute amount as the group
at large. Similar results were seen when we filtered on the combined subgroups that
either ate somewhat larger portions or much larger portions (Q. 31).

Figure 3. Percentage of respondents indicating greatly increased consumption. The populations
were all respondents to the survey, those who had lost 30 lbs and kept the weight
off for one year or more (Q. 2), those who felt they had consumed more calories that before their diet (Q. 31) and those who felt they ate larger portions (last two choices in Q.30)

In summary, of the food categories that were perceived as greatly increased by low
carbohydrate dieters, the greatest percentage of people had a diet characterized by
increased vegetables and salad greens but the subgroup that felt they had increased
the total amount of food (possible evidence of decreased energy efficiency) had the
largest percentage of people who had increased consumption of meat of all types and
butter.

Relation to CCARBS study

To our knowledge the only systematic internet study of the behavior of dieters using
strategies based on carbohydrate restriction is the CCARBS study, an Internet-based
prospective study collecting data annually on 2,357 participants [33]. The self-chosen cohort is similar to the group studied here: predominantly female
(88%), middle-aged (48 ± 11 yrs) and significantly overweight or obese (BMI at baseline
33.05 ± 8.36 kg/m2). A dietary history questionnaire was administered at baseline and at annual time
points. At the 1 yr time point, those who had lost weight consumed fewer calories
and less carbohydrate but more protein. Like the low-carbers group, the CCARBS population
who lost weight consumed more non-starchy vegetables but fewer servings of grain.
The group had favorable opinions on low carbohydrate diets and 90.3 % stated that
they were less hungry than on a conventional low calorie diet.

Narrative responses and medical problems

An unintended benefit of the survey is access to attitudes of the subgroup. The last
question in the survey "Please feel free to use this space to add any additional comments"
was quite general and it was anticipated that it would elicit comments on the questionnaire
itself. In fact, almost 1000 responses indicating personal reactions to low carbohydrate
dieting were received. We think this provides a remarkable insight into actual behavior
of low carbohydrate dieters. Similarly, an open-ended question asked if any improvements
in health conditions were noted also. The most common comment was that the respondents
felt they "had more energy." This is common from anecdotal information and posts on
the forum as well. Due, at least in part, to weight loss, it may also reflect relief
from the documented soporific effects of high carbohydrate diets. Table 4 tabulates some of the many health conditions that were reported to have improved.
Some, like PCOS, are known to be associated with high insulin and the effectiveness
of carbohydrate restriction is documented [34,35]. Others may be coincidental or a reflection of general improved health or weight
loss. These will be discussed in detail in a future publication.

The Atkins diet for the family practitioner

Low carbohydrate dieting may be driven by personal recommendations. The family practitioner
is likely to be approached by a patient whose acquaintance had good success with one
or another of these diets. The results described here present a view of a part of
the population where CRD has made an extremely positive impact on their life. The
variability in the answers to the questionnaire and the narrative responses indicate
there is not even a single Atkins diet and that great flexibility is available in
making recommendations on these diets . In the popular mind, and in the mind of many
professionals, the Atkins diet means the large increases in saturated fat. There is
a serious question about whether the importance of saturated fat is exaggerated –
its impact is likely to be very different on a carbohydrate-restricted diet than on
others [16,36,37] – but in any case, only about 20 % of respondents had the perception of greatly increasing
the amount of foods with high saturated fat. The major change in the intake for most
respondents was an increase in non-starchy vegetable consumption and the average diet
that emerges from the ALCF is a carbohydrate restricted diet that is high in non-starchy
vegetables, low in fruit and only slightly higher in meat compared to respondents'
baseline. Such an approach does differ from currently favored diets from most official
sources. Current recommendations call for increases in fruits and vegetables, a grouping
that does not seem to have much nutritional basis: on average, per 100 g, vegetables
have fewer calories than fruits, fewer carbohydrates, more antioxidants, more potassium
and are more likely to be integral to a meal rather than consumed in addition to a
meal.

Turning this around, the family practitioners can offer a strategy that was appealing
to people who describe themselves as being on the Atkins diet (and a subset who maintained
large weight loss) and which is not particularly iconoclastic. The data suggest that
low fat should not be recommended but neither should increases in fat or protein be
required.

On the last point, the recent reports of Women's Health Initiative highlight the limitations
of a low fat recommendation. After a period of 7–9 years of low fat diets, a large
cohort of women on average lost no weight and showed no improvement in risk for CVD
or stroke [38,39]. This result was, in fact, anticipated by the original Seven Countries Study [40], the Framingham study [41,42], the Tecumseh study [43] and the Nurses Health Study[44,45]. The continued emphasis on reduction in fat can no longer be considered part of scientific
knowledge.

Summary

The ALCF offers evidence for the family physician that carbohydrate restriction is
one of the useful choices for weight loss and general improvement of health. The narrative
reports allow access to patient perceptions and may be more useful in evaluating diets
than official recommendations. The evidence from the survey suggests physicians who
have been presented with patients desire to reduce carbohydrates are, in fact, open-minded
on the subject. The negative connotations given by experts to the term "Atkins diet"
may not be appropriate and the actual or perceived behavior of people who identify
themselves as being on such a diet allow physicians to design a diet that is likely
to be efficacious while not appearing iconoclastic. This last is probably the most
important lesson that can be learned from the Active Low-Carber Forums.

Abbreviations

ALCF: Active Low-Carber Forums

CRD: carbohydrate-restricted diet

NWR: National Weight Registry

UCCASS:Unit Command Climate Assessment and Survey System

Competing interests

MCV has held a consulting relationship with Atkins Nutritionals, Inc.

Acknowledgements

We are grateful to Wa'il al Wohaibi and other moderators of the Active Low-Carber
Forums for help in many aspects of this research.